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America's health care system is unraveling, with millions of hard-working people unable to pay for prescription drugs and regular checkups, let alone hospital visits. Jonathan Cohn traveled across the United States—the only country in the developed world that does not guarantee its citizens access to medical care—to investigate why this crisis is happening and to see firsthand its impact on ordinary Americans. Passionate, powerful, illuminating, and often devastating, Sick chronicles the decline of America's health care system, and lays bare the consequences any one of us could suffer if we don't replace it.

INTRODUCTION

BOSTON

It was 4:43 on a clear November afternoon when the paramedics found Cynthia Kline, pale and short of breath, slumped against a bedpost in her double-decker Cambridge home. Although Kline was in obvious pain, she seemed keenly aware of what was happening inside her 55-year-old body. One of her blood vessels had closed off, blocking the flow of blood to her heart. Minutes before, she had phoned 911, taken the nitroglycerin tablets prescribed for such an emergency, then waited for help to arrive—an ordeal that stretched out an agonizing extra few seconds while the rescue workers, having found the front door locked, scampered in through an open second-story window. Now, while the paramedics worked busily over her, noting vital signs consistent with cardiac distress, Kline turned to one of them with an anxious plea: Take me to Mount Auburn Hospital.

Kline, a teacher who worked with special-needs children, had no formal medical training. Yet her instinct about where to go was as sound as a seasoned cardiologist’s. Nearby Mount Auburn Hospital, a private teaching facility affiliated with Harvard Medical School, had some of the city’s finest doctors and nurses. More important, it had an intensive cardiac care unit that specialized in cases like hers. A few days earlier, staff at Mount Auburn had treated Kline’s advanced coronary disease by inserting a balloon into her circulatory system and then expanding it, in order to open up a partially blocked blood vessel. A variant on the very same procedure, cardiac catheterization, could be used in an emergency like this one, when the flow of blood through a vessel was almost completely cut off. Cardiac catheterization had saved literally thousands of lives across the country. The procedure had the potential to save Kline’s life, too, just as soon as she could get to the hospital and receive it.

But getting there was precisely the problem. On the way to Kline’s home, the ambulance driver had checked with a dispatcher about hospital availability. Mount Auburn was no-go: the emergency room there was overflowing, with no space to handle new patients. So as the paramedics wheeled Kline into the ambulance, one of them told her they would have to deny her request: Ma’am, we’re going to Cambridge Hospital instead.

Kline accepted the news, and maybe for a moment she thought it would be for the best. Although Mount Auburn was less than two miles away, Cambridge Hospital was even closer—just a short trip through the crooked, disjointed streets that surround Harvard Square. It was also a highly regarded medical facility in its own right, with a top-notch medical staff and a recently renovated emergency area fully capable of handling the majority of trauma cases that came its way. Had Kline’s condition remained as it was, it probably could have handled her case, too.

But just four blocks into the journey, Kline’s condition suddenly deteriorated. The instruments tethered to her arm could no longer detect a blood pressure; her heart rate, seventy beats per minute just moments before, was down to thirty-eight. Kline, strapped into a stretcher, was conscious through all of this—and increasingly agitated. At her side one of the paramedics, a kind-looking thirty-year-old, tried to calm her, explaining that the hospital was just seconds away. But as the ambulance made a right turn around one final corner, bringing the tall redbrick facade of Cambridge Hospital into view, Kline began to cry out: I’m going to die. I’m going to die.

It was 5:04 p.m., just twenty-nine minutes after Kline had first called 911 and about an hour into the heart attack, when the green-and-white ambulance pulled up to the emergency bay. Informed of the patient’s newly worsened state, attendants hustled the gurney into the hospital as the medical team began administering intravenous medication to increase Kline’s heart rate. For a while it looked like she might pull through. Her pulse went back up to forty-five beats per minute—a far cry from normal but at least not very low, as it had been in the back of the rig. Her breathing was more regular, too. Soon, however, a cardiology exam confirmed that Kline needed catheterization, something the staff at Cambridge Hospital could not do.

A nurse began inquiring about available hospitals, but now it was two hours since the chest pains had first begun—and time, finally, was running out. At 6 p.m. Kline’s heart stopped altogether. The doctors began performing the familiar ritual of cardiopulmonary resuscitation (CPR), pumping her chest and using electrified paddles to shock the heart back into a regular rhythm. It made no difference.

At 7:03 p.m., the trauma team relented. Cynthia Kline was dead.

Fifty-five-year-old women, particularly those who have a family history of coronary disease, die from heart attacks all the time. So as a forensic matter, at least, Kline’s death was unremarkable. But the technology that might have kept her alive existed—and it existed at a hospital that was less than five minutes away from her house. There was no guarantee that Mount Auburn’s doctors could have saved Kline. Still, as one source familiar with the case told the Boston Globe, whose story on the matter sparked a state investigation, Within an hour and a half they would have started to open her artery with a catheter. If you get the artery open there’s a 50-50 chance.

None of which would be so troubling if the overcrowding at Mount Auburn on that day in November 2000 were an isolated incident. It wasn’t. During a one-week period shortly after Kline’s death, a survey of seventy-six Massachusetts hospitals found that sixty-seven of them had used emergency crowding procedures or had diverted ambulance traffic. Massachusetts General Hospital (MGH), Boston’s largest medical facility, was closing its emergency room to patients forty-five hours per week. On the day of Kline’s heart attack, MGH was the next closest hospital with a cardiac catheterization unit—just three miles away. But it wasn’t taking new emergency patients that day, either.

And even if Kline was the city’s only known fatality from ambulance diversion, there was plenty of reason to think that the overcrowding epidemic was routinely jeopardizing the well-being of patients. In 2000, when the Massachusetts College of Emergency Physicians surveyed the directors of more than sixty emergency room (ER) facilities, four out of five said they’d diverted traffic at some point—and nearly 40 percent said overcrowding had led to adverse outcomes. Sometimes it was a matter of forcing ambulances to drive longer distances in order to find available hospital beds, or, as in Cynthia Kline’s case, of shunting people to hospitals less able to provide advanced treatment. And sometimes it meant that patients who got to the right emergency rooms had to wait many hours before receiving treatment. In some cases, patients actually had to wait inside the ambulances.

One thing was certain, though. The crowding problem made little distinction among patients of varying status, wealth, or influence. Bob Maher was the chief executive officer of Worcester Medical Center in central Massachusetts when he had a heart attack in November 2000, during an airplane flight to Boston. Paramedics met him at the airport, but his connections weren’t good enough to get him into MGH, which was, once again, on diversion. So the ambulance took him to another hospital several miles away. A woman named Nancy Ridley had her own troubles in the ER in May 2001. Suffering from a high fever and a hacking cough, she spent five hours waiting to be admitted for pneumonia at the Lahey Clinic in nearby Burlington. Ridley suffered no major health setbacks because of the wait, but the all too typical delay was the kind of problem she might have reported to the Massachusetts Department of Public Health—if only she hadn’t already been working there, as its assistant commissioner.

Boston, in other words, had an emerging public health crisis on its hands. And it wasn’t alone. In Atlanta, an ambulance crew carrying a patient in respiratory distress had to pull over and wait on the side of a highway for eighteen minutes because the nearest hospital was full and the paramedics were busy trying to find an alternative. Only when the patient went into full arrest—that is, he stopped breathing altogether—did the closest hospital find a way to take him. That patient lived, but others were not so fortunate. When the mother of a forty-year-old Cleveland man with liver failure called the local community hospital, staff there referred him to the MetroHealth Medical Center, which had more advanced lifesaving facilities. But when the ambulance arrived, MetroHealth was on diversion. The man ended up back at the community hospital, where, fifteen hours later, he died. In suburban Houston, when a twenty-one-year-old man was hit by a car, the local trauma centers turned him away because they had no room. He ended up on a helicopter ride to the next closest trauma hospital—in Austin, more than 150 miles away—and died shortly after arrival.

Fed up with incidents like that, a Texas neurosurgeon named Guy Clifton started an advocacy organization called Save Our ERs. The group’s first order of business was to compile data on Houston’s emergency services, and it produced sobering results. The city’s two level-one trauma centers, the hospitals capable of dealing with the most dire emergencies, were simultaneously on diversion for extended periods once every two days. I’ve been in this business for twenty-five years, Clifton said, and I’ve never seen anything like this.

The United States has not had a serious political discussion about health care reform since the early 1990s. But if the situation in our emergency rooms is indicative, then perhaps it is time for another one. Overcrowding in ERs, according to most experts, is actually a symptom of other systemic problems now plaguing medical care—from the downsizing of less profitable hospital services such as psychiatric wards, where emergency rooms must frequently send patients who need admission, to the swelling ranks of people without health insurance, whose untreated chronic conditions are more likely to become serious medical crises.

To the casual observer, these trends might seem unrelated. But they are all consequences of the way Americans pay for their medical care—and of how that system is now falling apart.

It’s a system of public and private insurance programs, supplemented by private charity, that dates back to the late 1920s—the time, not coincidentally, when medical care first became so expensive that large numbers of Americans literally could not afford to get sick. And it’s a system that has survived for as long as it has because, by the late twentieth century, it had financed a massive industry dedicated to medical care while putting its services within reach of the majority of Americans. As critics have repeatedly noted, these arrangements have never met everybody’s needs; the poor, in particular, have frequently struggled to find medical care either through doctors or through safety-net hospitals. But the U.S. health care system has generally worked well enough—or, more precisely, it has worked well for enough people—to withstand efforts at redesigning it.

Probably never was this more conspicuous than in the early 1990s, when President Bill Clinton proposed his now infamous reform plan. Under Clinton’s proposal, the government would have made certain everybody had insurance coverage and, along the way, refashioned the whole health care industry—doing for Americans what the Canadian, Japanese, and western European governments have long done for their citizens. But Clinton’s gambit failed. And while many critics would later blame its demise on either Clinton himself or the special interests that fought him, a more crucial impediment to reform may have been public ambivalence.

Most Americans, after all, still had health insurance in the early 1990s and rather liked it the way it was. When they needed medical care, they got it. To these people, the possibility of losing insurance and the consequences that might follow just didn’t seem real enough to warrant such a sweeping overhaul—particularly if it would be at the hands of the government, an institution few people believed was capable of such a massive and complicated undertaking. I’ve got pretty good health care and 80 percent of the country has pretty good health care, said one caller on a CNN show in August 1994, summing up a national mood that had turned decidedly against comprehensive reform. Why are we doing the wholesale changes?

And yet if Americans truly believed they had rejected radical change with Clinton’s health care plan, they were in for a surprise. The arrangements for financing medical care, from the private insurance workers got on the job to the public insurance programs that provided for retirees, were already faltering, because they could neither control nor keep up with the rising cost of medical care. The strain was building not just on emergency rooms, but also on charity clinics and public hospitals. Sooner or later, something was going to give.

In retrospect, then, the real issue in 1994 was not whether America’s health care system should change but how. Who would be in charge? Who would benefit? Who would suffer?

What follows in these pages is the answer to those questions, told through the stories of a few ordinary Americans who came to learn them firsthand.

ONE

GILBERTSVILLE

New York’s Leatherstocking Country sits at the northern foothills of the Catskill Mountains, a few hours’ drive from Manhattan. The name is a reference to the leggings that colonial settlers wore during the 1700s, but it was James Fenimore Cooper who immortalized the region in the early 1800s, when he used it as the setting for his five books about the frontier hero Natty Bumppo, a collection that later became known as the Leatherstocking Tales. To see the area today is to glimpse a landscape remarkably like the one that first captured Cooper’s imagination: a succession of hills and dales rolling through the countryside; beautiful and thriving villages nestled in the narrow, rich, and cultivated valleys, with only the occasional gas station and roadside pizza shack to pierce the romantic and picturesque character. For the people who live in Leatherstocking Country now, this largely unmolested geography provides precious insulation from the rest of New York—even, it would seem, from modernity itself.

Perhaps nowhere is this more evident than in the village of Gilbertsville. Gilbertsville is a two-hour drive from Syracuse, the closest city with a major airport, and the last part of the journey takes place along a winding road, more than 1,000 feet up in the hills. Gilbertsville becomes visible only after the final turn, when the road descends into a valley, depositing drivers near the entrance to Major’s Inn—a Tudor-style building that hosts such events as the annual Gilbertsville Quilting Fair. Here Gilbertsville’s commercial district begins and nearly ends, with a small grocery store, a quilt shop, and a few offices operating out of more Tudor-style storefronts that line one side of the street. The buildings look almost precisely as they did when they were built in the 1890s, after a fire destroyed the old business district. The effort to replicate a small English town was apparently the inspiration of Joseph T. Gilbert III, whose great-grandfather, Abijah Gilbert, helped settle the township in the 1780s after migrating from Great Britain.

Some of Abijah’s direct descendants still live in Gilbertsville. In fact, say the locals, many of the 377 people that the 2000 U.S. Census placed in Gilbertsville have roots in the area that go back at least 100 years. More than surnames were handed down over the generations. The people in this part of New York have a long-standing reputation for hard work, conservative values, and attachment to the land—a reputation that still seems fitting today. The inhabitants attend church regularly and strongly prefer conservative politicians, electing mostly Republicans to the five-member village governing body. As for their awareness of their heritage, perhaps the most celebrated episode in Gilbertsville’s modern past came in 1982, when its residents won a seventy-year fight to block construction of a proposed dam that would have flooded most of the village. They prevailed by methodically cataloging the architectural heritage of every local building, commercial and residential, then successfully lobbying to have the entire village placed on the National Register of Historic Places, forever protecting it from disturbance.

It was four years after that victory that Gary and Betsy Rotzler moved to Gilbertsville, fitting into the community fabric almost seamlessly. They’d grown up together in neighboring Delaware County. Although Betsy was born in the Bronx, Gary’s Leatherstocking lineage went back a dozen generations, to its very earliest days as a settlement in the New World. (Family legend had it that one of Gary’s ancestors came from Britain to the United States on the ship immediately following the Mayflower.) The long hair Gary wore during his adolescence was typical for boys in the 1960s and early 1970s, but in most other respects he and Betsy were remarkably traditional. They had become high school sweethearts after going on a date to the county fair in 1975, while Gary was a junior and Betsy still a freshman, then continued dating after Gary went to college upstate. On June 25, 1978, just one day after Betsy’s graduation from high school, the two were married in a small ceremony held at the home of Betsy’s parents. A year later they would have their first child, a daughter named Sarah. Two more would follow: another daughter, Amanda; and then a son, Luke.

The Rotzlers came from relatively modest roots: Gary’s father was a diesel mechanic who worked for the local highway department; Betsy’s parents ran a residential treatment center for alcoholics. But by the time the couple came to Gilbertsville, the Rotzlers had every reason to expect they were on their way to realizing the American dream. Gary was noted for being industrious, having missed not a single day of classes in college. Shortly after graduating, he began working at Bendix, a large aerospace manufacturing company—first as a design technician at a plant in the nearby town of Sidney, later as a field engineer managing the company’s midwestern clients from Dallas, Texas. Another engineering job at the Bendix Sidney plant had lured the Rotzlers back to central New York—where they hoped to remain, for good. Betsy, for her part, had chosen to stay at home and raise the three children, getting involved primarily in activities that revolved around them, like the La Leche League for mothers who were breast-feeding and, later, the Girl Scouts. Around town, she would become known for her artistic flair, particularly the individualized Raggedy Ann–style dolls that were her trademark.

But the American dream would prove fleeting for the Rotzlers, just as it did for much of central New York in the early 1990s. The regional economy depended on defense manufacturing jobs, like Gary’s, that vanished as Washington cut the Pentagon budget and a recession fell over most of the country. One by one, Gary’s colleagues lost their jobs. In 1993, he lost his, too. And while Gary would find ways to replace some of his lost wages over the ensuing two years, he would have a much tougher time coming up with something else: health insurance. Like most working Americans, Gary had always depended on his employer to provide medical coverage; when the job was gone, so was his coverage. And even after Gary finally found full-time work, he still couldn’t get insurance for his family, because his employer—a company for which he’d worked previously—was no longer providing benefits to many of its employees.

None of this was unusual. On the contrary, it was emblematic of a change then taking place across the country: the erosion of job-based insurance, on which the U.S. health care system had been based for most of the twentieth century. The steady decline of job-based health coverage was the primary reason that the number of Americans without health insurance, nearly 40 million people by the time Gary and his family joined their ranks, was rising by the early 1990s. And, like Gary, the majority of these newly uninsured were neither destitute nor truly jobless. Instead, they were people who, as the saying goes, played by the rules of society—finding whatever employment they could, frequently working at several part-time jobs, but with no idea when they’d be able to get medical coverage again.

For some of these people, having no health benefits would eventually mean financial calamity. For others, it would mean a serious, even life-threatening medical crisis. For the Rotzler family of Gilbertsville, New York, it would come to mean both.

Although nobody knows for sure who invented insurance, historians generally trace its development back to ancient Babylonian traders who feared that their shipments across the desert might fall prey to bandits, dust storms, or camels with shoddy knees. In order to protect themselves financially, groups of these merchants decided that they would contribute to a fund; if a merchant’s shipment disappeared, he could then take payment—or make a claim—to cover his losses. Later, the Greeks and Romans extended insurance beyond commerce by creating so-called benevolent societies, which pooled contributions from members to finance burials for the deceased. From there, the practice evolved into the mutual protection societies that the guilds of medieval Europe ran for their members, providing financial support in case of disabling injury or death. Eventually companies dedicated exclusively to providing insurance came into existence. The most famous among them was Lloyds of London, whose protection of merchants helped trade to flourish throughout the British Empire.

America’s first private insurance company is believed to have appeared during the colonial era, when Benjamin Franklin established a firm to insure the homes of Philadelphia against the risk of fire. But it was not until the early twentieth century that the idea of using insurance to help people deal with illness started to get serious attention. At that time medicine was just entering what we now consider its modern era. With the development of sanitary techniques (to prevent infection) and sophisticated understanding of opiates (to dull pain), surgery had become more effective and widespread, turning hospitals from places where people were lucky to survive to places where people expected to be cured. Physicians, meanwhile, had developed formal education and certification protocols, giving them a claim to expertise beyond that of quacks and witch doctors. As one scientist of the era famously remarked, It was about the year 1910 or 1912 when it became possible to say of the United States that a random patient with a random disease consulting a doctor chosen at random stood better than a fifty-fifty chance of benefiting from the encounter.

But with this progress in medicine came new costs. Doctors and hospitals expected to be paid well for their services, particularly since they were investing so heavily in their training and equipment. And by the 1920s, the bills were becoming more than many Americans could bear. With the onset of the Great Depression, the average cost of a week in the hospital began to exceed what the majority of Americans earned in a month, making illness a scary financial proposition for even the thriftiest middle-class households—and forcing many people to skip medical care altogether. Very few of these families are indigent in the accepted meaning of that word, the economist Louis Reed explained in 1933. They have a home, they buy their own food and clothing and pay their doctor’s bills in ordinary illness. But when a serious illness…occurs, these families are unable to pay their way.

Reed had gotten his information from the Committee on the Costs of Medical Care, a blue-ribbon commission that had spent five years conducting the first national census on health care. But not all of its findings were so bleak. In particular, the committee observed that large expenses were concentrated among a small group of people, the ones with the most serious medical problems. Since everybody had at least some risk of experiencing such a crisis at some point in his or her life, the committee recommended that Americans do what the ancient merchants had done, and assume some form of collective responsibility for medical costs. In other words, it recommended the creation of insurance for medical care.

The key question, of course, was how. Other industrial countries were starting to give insurance to every citizen, through the government or government-sponsored organizations, thereby spreading the financial burden of medical spending as widely as possible. Health care in these countries was thus on the way to becoming a right, rather than a privilege. But calls to do the same thing in the United States had run into stiff political resistance ever since the late progressive era, when state-level reformers in California and New York first proposed it. Large corporations feared that government management of medicine might lead to interference elsewhere in the private economy. Private insurers weren’t ready to concede a possible line of business. And physicians simply didn’t want the government meddling with their work or incomes. Physicians would prove a particularly potent lobby during the first half of the twentieth century, to the point where Franklin Roosevelt is said to have dropped health insurance from the Social Security Act because he feared that the hostility of state medical societies and the American Medical Association would undermine the whole initiative.

The physicians were so worried about outside interference, private or public, that many would have been content to do absolutely nothing about the financing of medical care during the 1930s. But it turned out that consumers weren’t the only ones struggling financially. Hospitals needed help, too. In the years leading up to the Depression, while the economy was booming, hospitals had gone on a building binge, constructing new wings and outfitting them with the latest, most expensive equipment. Now all those brand-new facilities were either empty or full of patients too poor to pay their bills, presenting the hospitals with a crisis of their own.

One of those institutions was Baylor Hospital in Dallas, Texas, which by 1929 was just 30 days ahead of the sheriff because of its mounting debts. But Baylor also had a new administrator, Justin Kimball, with an idea for saving the hospital financially. Kimball, who had come to Baylor from the Dallas public schools, decided to approach his old colleagues with an offer: the hospital would provide up to twenty days of care to any teacher willing to pay a monthly contribution of fifty cents, so long as at least three-quarters of the system’s teachers agreed to be part of the plan. Meeting that three-quarters threshold was crucial: Kimball, who had access to the school system’s personnel records, had calculated that it would guarantee enough contributions from healthy teachers to cover the medical expenses of those few who needed care. But Kimball had no problem recruiting so many enrollees, as the promise of economic security for such a modest price turned out to be an easy sell. On the first day of Christmas vacation in 1929, a teacher who had broken her ankle on the ice showed up at Baylor’s emergency room, becoming the first beneficiary to make a claim under modern hospital insurance.

As word of the success at Baylor spread, hospital administrators around the country copied the model and improved on it—eventually establishing nominally independent plans that paid for services based on fees the hospitals set. In Sacramento and later central New Jersey, hospitals joined together to create a plan that offered beneficiaries care at any local facility, not just one, thereby starting the nation’s first multihospital insurance plan. In 1934, the founder of a plan based in Saint Paul, Minnesota, decided to illustrate his advertising posters with a blue cross. The image caught on as fast as the plans themselves, and by 1938, 2.8 million people were enrolled in Blue Cross plans that had established themselves across the country.

Like the original scheme at Baylor, most of the early Blues plans concentrated on offering coverage to groups of employees—or, occasionally, through fraternal societies like the Elks Club—because that was the best way to guarantee a group of subscribers sufficiently large to make the insurance math work. As commercial insurers got into the health business, they, too, focused on large workplaces. A habit was forming—one the government would soon make very hard to break. During World War II, federal officials decreed that fringe benefits were exempt from wartime controls on wages. That encouraged employers to offer more generous health insurance, since better benefits were one of the few enticements they could use to attract new workers in such a tight labor market (with much of the able-bodied workforce busy fighting overseas). Soon the government also decided that money spent on health insurance provided by employers would not be subject to the income tax. This increased the demand for such benefits—since, to a worker, a dollar of health insurance became more valuable than a dollar of salary.

Linking insurance to employment meant that businesses were, in effect, becoming responsible for their employees’ well-being. But that was not a burden corporate America seemed to mind. On the contrary, businesses eagerly pursued this role because they believed it would cement workers’ loyalty while undermining the appeal of national health insurance—something they continued